Models of the entire or particular regions or systems of the human anatomy are commonly employed in the general education and training of medical personnel as well as specialized training of specialists, surgeons, surgical staff, and other medical personnel in performance of specialized diagnostic, therapeutic, and surgical procedures. See, for example U.S. Pat. Nos. 5,104,328, 5,356,295, 6,062,866, 6,234,804, 6,267,599, 6,336,812, 6,568,941, and 6,780,016. Neonatal models of the developing fetus are provided to educate and inform prospective parents as disclosed in the above-referenced '295 and '328 patents. Models of the thoracic region and cardiovascular system are provided to educate cardiologists and surgeons as disclosed in the above-referenced '804, '599, '866, and '016 patents. In the above-referenced '941 patent, tactilely realistic, soft and pliant, models of the female breast encasing hard internal lesion models, and that may be transparent at least in part, are disclosed for needle biopsy training. A dynamic and accurate anatomical model of skin, muscle, bone, and ligaments of the human knee with a “true-to-life” feel is provided as the “Hillway Knee” by Hillway Surgical Ltd., Chichester UK, for simulated arthroscopic and open training procedures and to teach patients about to undergo knee surgery. A wide variety of simulations of regions and systems of the human body are disclosed in the above-referenced '812 patent. A housing is provided and multiple simulations of normal and abnormal internal organs and tissues of a body region of various degrees of complexity are provided to be selectively placed in the housing for training a surgeon, particularly in performing laparascopic procedures performed through the housing.
It is necessary to train surgeons and urologists in performing certain surgical procedures in the abdominopelvic region of the human body, particularly procedures for treating incontinence. Incontinence is a condition characterized by involuntary loss of urine, beyond the individual's control, that results in the loss or diminution of the ability to maintain the urethral sphincter closed as the bladder fills with urine. Male or female stress urinary incontinence (SUI) occurs when the patient is physically or emotionally stressed.
One cause for this condition is damage to the urethral sphincter or loss of support of the urethral sphincter, such as can occur in males after prostatectomy or following radiation treatment, or that can occur due to pelvic accidents and aging related deterioration of muscle and connective tissue supporting the urethra. Other causes of male incontinence include bladder instability, over-flowing incontinence and fistulas.
The female's natural support system for the urethra is a hammock-like supportive layer composed of endopelvic fascia, the anterior vaginal wall, and the arcus tendineus (a distal attachment to the pubic bone). Weakening and elongation of the pubourethral ligaments and the arcus tendineus fascia pelvis, weakening of the endopelvic fascia and pubourethral prolapse of the anterior vaginal wall, and their complex interaction with intraabdominal forces are all suspected to play a role in the loss of pelvic support for the urethra and subsequent hypermobility to an unnaturally low non-anatomic position, leading to urinary incontinence.
In general, continence is considered to be a function of urethral support and coaptation. For coaptation to successfully prevent or cure incontinence, the urethra must be supported and stabilized in its normal anatomic position. A number of surgical procedures and implantable medical devices have been developed over the years to provide urethral support and restore coaptation.
Females can also exhibit cystocele, a condition due to laxity of the pelvic floor wherein the bladder extrudes out and downwards causing SUI. The severity of this bladder collapse is rated between Grades one through four. In Grade four cystocele, the bladder extrudes out of the vaginal opening. The treatment of choice for this condition includes the reduction or closing of the pelvic floor opening from which the bladder descends using sutures. Further surgical procedures and implantable medical devices have been developed to correct cystocele by supporting the bladder.
The present application is directed to the training of surgeons and urologists in the treatment of SUI and chronic urinary incontinence due to inability of the urethral sphincter to close or remain closed as bladder fluid pressure builds through the implantation of implantable medical devices in the abdominopelvic region. Currently, incontinence treatments of choice involve implantation of a Kaufman Prosthesis, an artificial sphincter (such as the AMS-800 Urinary Control System available from American Medical Systems, Inc.), or a urethral sling procedure in which a urethral sling is inserted beneath the urethra and advanced in the retro pubic space, and perforating the abdominal fascia. Peripheral portions of the elongated urethral sling are affixed to bone or body tissue, and a central portion of the elongated urethral sling extends under the urethral or bladder neck to provide a platform that compresses the urethral sphincter, limits urethral distention, and pelvic drop, and thereby improves coaptation.
Male and female urethral sling procedures are disclosed in commonly assigned U.S. Pat. Nos. 6,382,214 and 6,652,450, for example, and further female urethral sling procedures are described in commonly assigned U.S. Pat. Nos. 6,641,524 and 6,612,977, for example, and publications and patents cited therein. The implantation of certain urethral slings involves the use of delivery systems configured for and techniques that involve transvaginal, transobturator, supra-pubic and pre-pubic exposures or pathways.
The above-referenced '214 patent describes apparatus and methods for treatment of male incontinence and female cystocele repair in which a urethral sling material is positioned between the descending pubic rami of the pubic bone. In such an operation a “hammock-like” urethral sling material is sutured below the urethra in males, or below the posterior bladder wall in the case of cystocele in females. The urethral sling material may comprise synthetic material or cadaveric or autologous fascia and may or may not be absorbable over time.
In the male case, the urethral sling applies passive compression against the bulbar urethra. The compression, either by itself or in conjunction with urethral mobility, prevents urine leak during strain. If additional passive pressure is required on the urethra after surgery is completed, collagen or other bulky material can be injected with a tiny needle through the perineum, causing more pressure created by the bulky material on one side (the lower or caudal side) by the urethral sling, and on the other (the upper or superior) side compressing the urethra.
In surgical approaches disclosed, for example, in commonly assigned U.S. Patent Application Publication Nos. 2005/0043580 and 2005/0065395, elongated self-fixating urethral slings are implanted for treating female prolapse employing a pair of sling implantation instruments or tools. The sling implantation tools comprise a handle with an elongated needle portion terminating in a needle distal end adapted to be coupled to free ends of the urethral sling and have mirror image right and left handed needle shapes. The sling implantation tools disclosed in the above-referenced 2005/0043580 publication have a curvature in a single plane and correspond generally to the BioArc™ SP and SPARC™ single use sling implantation tools sold by American Medical Systems, Inc., in a kit with an elongated urethral sling. The sling implantation tools disclosed in the above-referenced 2005/00653985 publication have a curvature in 3-dimensional space and correspond generally to the BioArc™ TO and MONARC™ TO single use sling implantation tools sold by American Medical Systems, Inc., in a kit with an elongated urethral sling. In each such sling implantation tool, the needle portion has a proximal straight portion extending from the handle and a distal shaped portion terminating in a needle distal end. The needle portion is sized and shaped so that the distal end may initially be moved through an abdominal incision and advanced posterior to one of the right and left posterior ischiopubic pubic ramus of the pelvic girdle spaced from the bladder to a vaginal incision in the region of the vaginal apex.
The needles of the BioArc™ TO and MONARC™ TO implantation tools are curved in three-dimensional space so that the needle tip may be advanced toward and through the obturator membrane of the obturator foramen, and then toward a vaginal incision in the region of the vaginal apex. The surgeon employs a learned wrist motion of the hand grasping the handle and pressure feedback felt through the handle to guide advancement. Also, the surgeon may palpate the vaginal wall with the fingers of the free hand to locate the needle tip and guide it toward and through the vaginal incision to expose the needle tip. The procedure is repeated using the other of the right and left hand sling implantation tools to advance the needle tip through a second skin incision and the other of the respective right and left obturator membranes to expose both needle tips through vaginal incisions.
In this way, right and left subcutaneous transobturator pathways are formed through the right and left obturator foramen and connective tissue attached to the right and left posterior ischiopubic pubic ramus of the pelvic girdle. This procedure is preformed without visualization of the needle tip, and care must be taken to avoid deviating posteriorly and penetrating the bladder and to otherwise avoid damaging any of the obturator nerves, the superficial epigastric vessel, the inferior epigastric vessel, the external iliac artery and the internal iliac artery.
The free ends of the elongated urethral slings are implanted through the pathway employing the right handed and left handed sling implantation tools as further described in the above-referenced. 2005/0043580 and 2005/0065395 publications. Generally speaking, the free ends of the elongated urethral slings are coupled to the needle distal ends, and portions of the sling are drawn through the pathways to draw a central sling portion against the urethra to provide support. The free ends of the elongated urethral slings include dilating connectors for connecting with the needle distal ends so that the pathways are dilated as the connectors are drawn through them. The dilating connectors are drawn out through the abdominal skin incisions and are severed from the urethral sling. The urethral sling portions other than the central portion may be covered with a detachable protective film sheath that is then withdrawn exposing mesh that is sutured to subcutaneous tissue layers. Chronic tissue ingrowth into the mesh pores stabilizes the urethral sling. A similar procedure may be possible to install an elongated urethral sling to support the male urethra to alleviate incontinence as described in regard to certain embodiments in the above-referenced '450 patent.
Typically, surgeons and urologists practice the right and left hand manipulations of the sling implantation tools to create the pathways and draw a urethral sling through them on cadavers before performing their first patient procedure. Cadavers are not always readily available for the initial training, and repeated training is not convenient. Moreover, it is not possible to visualize the advancement of the needle tip within the cadaver body, and it is not possible it assess whether damage has been done to internal organs, vessels, and nerves in the abdominopelvic region without destructive autopsy at the site.
Similar problems are encountered in training to perform other procedures involving blindly advancing a needle or other surgical instrument around the internal organs and alongside bones, nerves, and blood vessels to effect other treatments and implantations of implantable medical devices in the abdominopelvic region.
Consequently, it would be desirable to provide a realistic training model of the abdominopelvic region to facilitate training in the performance of these procedures and education of patients.